T. Christian Miller, a ProPublica reporter, discusses his investigation into EviCore's controversial algorithm that determines health insurance claim approvals. He reveals how adjustments to this algorithm prioritize cost savings over patient care, resulting in increased claim denials. The conversation highlights the devastating impact of algorithmic decisions on real patients, showcasing the dangerous implications of automated systems in healthcare. Miller raises alarm over the potential conflicts of interest in the system that can lead to life-threatening delays for individuals in need of care.
Health insurers are increasingly utilizing algorithms to determine claim approvals, often prioritizing cost reduction over patient care, leading to serious risks.
The tragic case of Little John Cupp illustrates the deadly consequences of algorithm-driven claim denials, emphasizing the urgent need for ethical healthcare practices.
Deep dives
Puerto Rico as an Innovation Hub
Puerto Rico is positioned as a vibrant innovation hub, attracting both startups and established global companies. The island boasts a highly skilled, bilingual workforce and offers competitive tax incentives that make it an appealing location for businesses looking to expand. This unique ecosystem not only nurtures new ideas but also fosters collaboration among various players in the industry. As a result, Puerto Rico emerges as an ideal place for entrepreneurs to establish and grow their ventures.
Algorithmic Decision-Making in Healthcare
Many health insurers are increasingly relying on algorithms to determine the approval of medical claims, which can significantly impact patient care. The company Evacor, for example, automates the prior authorization process and modifies its algorithms to reduce the likelihood of claim approvals. This practice has raised concerns, as seen in the case of patients who face delays or denials for necessary treatments, ultimately jeopardizing their health. Insiders suggest that the pressure to cut costs may incentivize such companies to prioritize financial savings over patient needs.
Consequences of Denied Medical Claims
The story of a patient named Little John Cupp highlights the severe consequences that can arise from algorithm-driven claim denials. After multiple rejections for a heart catheterization recommended by his doctor, Cupp finally received a scan, which revealed serious heart issues; however, he tragically passed away from a heart attack shortly after. This case underscores the potential dangers of delayed or denied treatments due to automated decision-making processes. It raises critical questions about the balance between cost-cutting practices and providing timely and necessary healthcare for patients.
Some of the biggest health insurers in the country are turning to an algorithm to help determine if a medical claim will be approved. That’s according to a recent investigation led by ProPublica into EviCore, a contractor used to outsource prior approval requests for much of the insurance industry. The investigation found that EviCore tweaks an algorithm to increase the likelihood those claims will be denied, which means lower costs for insurers but more patients losing access to potentially lifesaving care. Marketplace’s Meghan McCarty Carino spoke to ProPublica’s T. Christian Miller, who co-reported this story.
Get the Snipd podcast app
Unlock the knowledge in podcasts with the podcast player of the future.
AI-powered podcast player
Listen to all your favourite podcasts with AI-powered features
Discover highlights
Listen to the best highlights from the podcasts you love and dive into the full episode
Save any moment
Hear something you like? Tap your headphones to save it with AI-generated key takeaways
Share & Export
Send highlights to Twitter, WhatsApp or export them to Notion, Readwise & more
AI-powered podcast player
Listen to all your favourite podcasts with AI-powered features
Discover highlights
Listen to the best highlights from the podcasts you love and dive into the full episode